Do you remember the nirvana-like feeling you got the first time someone taught you how to copy and paste? It was like a whole new world of possibilities opened up at your fingertips. No longer would you waste valuable time retyping words over and over again until your knuckles turned white.
But with great power, comes great responsibility. And when inputting patient data into an EHR, copy-and-pasting can have very serious consequences, including an increased risk of medical errors and possible CMS allegations of upcoding.
According to a recent AHIMA report, 79-90% of physicians use the copy/paste function in their EHRs, and somewhere between 20-78 percent of physician notes are copied text. With this many physicians relying on the tactic, it’s not surprising to see a growing number of errors made within EHR systems.
Some doctors still view the technique innocuously. So where does the true danger lie for physicians?
Dangers of Copy-and-Pasting in Healthcare
Picture an intensive care unit (ICU), where a patient is in a delicate condition and any small change in treatment or medications could affect the outcome of the case. Using the previous day’s treatment plan the following day is often routine.
However, the previous day’s plan may not include the most up-to-date information, and copying over old charts could put the patient at fatal risk if crucial new data is lost during the process.
Or let’s say the same ICU unit was to copy a medical procedure from a previous encounter when updating the treatment plan. If not caught by the billing department, the procedure could potentially be coded for twice and lead to an overpayment and possible audit in the future.
Copy and pasting are of such great concern that Diane Warner, Director of AHIMA, addressed the issue in front of a large crowd at this year’s MGMA. Warner claimed that inappropriately using copy and paste functions in EHRs has led to medical errors and practices inappropriately billing for services they never provided.
In Warner’s judgment, though, most practices are not upcoding their services on purpose. They’re just trying to ease a workload that has already been besieged by mounting government pressure.
Should Doctors Copy and Paste At All?
The good news is that there are times when using copy/paste functionality to streamline workflow is appropriate. The command should be applied for copying demographics, regular patient medications, problem lists, long-standing allergies, and labs.
But appropriate use of the functionality is key. Whenever you’re dealing with a new condition, treatment, or patient, it’s always best to manually input medical data. Staff members should verify a patient’s care information individually to ensure accuracy.
While most of us can agree that copy-and-pasting is a blessing, it carries with it a warning. Be careful when employing this commonly-used functionality. It could get you in hot water faster than you think.
Do you know what you need when setting up a new medical practice?
